Inside this edition

Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East, and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

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This publication contains articles previously published on our Provider News Center.June 2018 Recap

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For articles specific to your area of interest, look for the appropriate icon:

Professional Facility Ancillary

Inside this editionAdministrative

● Coming soon: Changes to the Provider News Center

● Reminder: Important information regarding obtaining a PROMISeTM ID to render services to CHIP members

● Required lead time when updating your provider information

● New EFT requirement

Billing & Reimbursement ● Important information for professional providers

● Enhanced claim edits to support correct coding principles

● Services eligible for reimbursement above the capitation rate

● Updated payer ID grids now available ● Reminder: Billing and cost-sharing for individuals enrolled in the Qualified Medicare Beneficiary program

● Pass-through billing not permitted by Independence

● ICD-10 in Action: Coding guidelines and conventions – Excludes1 and Excludes2 notes

BlueCard®

● Reminder: Billing guidelines for BlueCard® claims for lab, DME, and specialty pharmacy providers

● New medical record retrieval coordinator for ACA programs

Health & Wellness ● Registered Nurse Health Coaches: Supporting providers and patients

Medical ● Reminder: Updates to the list of specialty drugs that require precertification

● Site of service changes and new coverage option for Benlysta® now in effect

● Updates to Direct Ship Drug Program request forms

● Updated information regarding our Cardiology Utilization Management Program

● Reminder: Changes to reimbursement of consultation codes for Medicare Advantage HMO and PPO members

● Updated policies on SCODI ● Updated coverage positions on zoster and hepatitis B vaccines for commercial members

● Four drugs to be added to Most Cost-Effective Setting Program

● View up-to-date policy activity on our Medical Policy Portal

NaviNet® Resources ● Update your provider record with the NaviNet® Provider File Management transaction

Quality Management ● New credentialing process and contact information

● Standards for medical record documentation: Medical record review

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IVE Coming soon: Changes to the Provider News Center

Published June 12, 2018

We are excited to announce that you will soon see changes to the Independence Provider News Center. We are making enhancements to the website that include a new look and better navigation. Our intention is to make it easier for you, our network providers, to get the latest news from Independence.

Enhanced resource pagesTo make important information easier to find, we are reorganizing and highlighting several resource pages.

NaviNet® ResourcesThe NaviNet Resources page will now be separated by categories to make it easier to find information on:

● Self-service requirements ● Authorizations transaction resources ● NaviNet user guides and webinars

Opioid AwarenessWe created a dedicated section that contains a repository of tools and resources to assist you in managing your patients who are prescribed these medications.

Utilization Management – NEW!Resources on our different utilization management programs are now in one convenient location. Here you will be able to access common resources used by all utilization management programs, such as:

● Preapproval/Precertification List ● Medical Policy Portal ● Services that require precertification

− Commercial − Medicare Advantage

Our utilization management program resources will also be categorized by the different entities managing these programs:

● AIM Specialty Health® (AIM), an independent company ● CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent specialty benefit management

company ● Magellan Healthcare, Inc. (Magellan), an independent company

Email feedback linkWe will also be incorporating an email feedback link that provides an easy way for you to contact us when you have questions related to a specific article. This feedback link will open an email that populates our email address in the To field and the title of the article in the Subject line.

Stay tuned for the release of the enhanced Provider News Center.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.

Search tipsFollow these tips to easily find the information you need on our Provider News Center. When using the Search function in the top-right corner of the page:

● try to limit your search to a single keyword or phrase;

● use quotations to search for an exact phrase; ● use the wildcard (*) when you are unsure

of the tense used or the complete phrase (e.g., type in “precert*” when trying to locate articles with mentions of precertification or precertified), this type of search is also helpful if you are unsure of the complete spelling of a word;

● switch the display of search results by using the Sort by Relevance and the Sort by Date functionalities;

● use Ctrl+F and type in a keyword/s to quickly identify where it is displayed on the screen.

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IVE Reminder: Important information regarding obtaining a

PROMISeTM ID to render services to CHIP membersPublished June 19, 2018

As previously communicated, the Pennsylvania Department of Human Services (Department) is implementing the Affordable Care Act provision that requires all providers who render services to Children’s Health Insurance Program (CHIP) members be enrolled with the Department as a CHIP provider. Upon enrollment, the Department issues providers a Provider Reimbursement and Operations Management Information System (PROMISe) identification number. This PROMISe ID is required in order to receive payment for services rendered to CHIP members.

Note: All providers in the CHIP network need a PROMISe ID for each location at which they see CHIP members. In addition, every provider who renders services to CHIP members through a group practice needs a PROMISe ID for each location at which they render services.

Answers to common questionsSome providers have raised questions about the enrollment application fee payable to the Department. The Department has advised that individual providers are not required to pay this fee. The $560.00 application fee applies only to institutional providers such as inpatient facilities, extended care facilities, and durable medical equipment/medical suppliers.

Some providers may have been hesitant to enroll due to the uncertainty regarding the federal reauthorization of CHIP. We are pleased to announce that the CHIP program has been reauthorized for the next ten years!

Also, remember that enrolling in CHIP does not mean providers must accept Medical Assistance beneficiaries who are not CHIP members.

How this affects claims processingPlease note that claims for services rendered to a CHIP member that are submitted to Keystone Health Plan East by a provider who does not have a PROMISe ID corresponding to the location where the services were rendered may not receive payment in accordance with Department requirements.

Learn moreIf you have any questions or issues with the enrollment process, contact the Provider Enrollment Hotline at 1-800-537-8862, select options 3, 1, 1, and finally option 4 to speak to a representative. You can also visit the Pennsylvania Department of Human Services website to access the application, requirements, and step-by-step instructions related to the enrollment process. Providers are encouraged to enroll electronically.

You can still register for your PROMISe ID!The deadline for CHIP providers to enroll with the Department was December 31, 2017. However, there is still time to enroll and continue receiving payment for services rendered to CHIP members.

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IVE Required lead time when updating your provider

informationPublished June 25, 2018

Independence would like to remind you that submitting changes in a timely manner helps to ensure prompt payment of claims, delivery of critical communications, seamless recredentialing, and accurate listings in our provider directories. In accordance with your Provider Agreement (Agreement), the Provider Manual for Participating Professional Providers (Provider Manual) and/or the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers (Hospital Manual), as applicable, you are required to notify Independence whenever key provider demographic information changes.

Professional providersAs outlined in the Administrative Procedures section of the Provider Manual, Independence requires 30 days advance written notice to process most updates, with the exceptions noted below:

● 30-day notice. Independence requires 30 days advance written notice for the following changes/updates to your practice information:

− updates to address, office hours, total hours, phone number, or fax number; − changes in selection of capitated providers (HMO primary care physicians [PCP] only); − addition of new providers to your group (either newly credentialed or participating); − changes to hospital affiliation; − changes that affect availability to patients (e.g., opening your panel to new patients).

● 60-day notice. Independence requires 60 days advance written notice for closure of a PCP practice or panel to additional patients.

● 90-day notice. Independence requires 90 days advance written notice for resignation and/or termination from our network.

Submitting updates and/or changes*Most changes to basic practice information can be quickly submitted using the Provider File Management transaction on the NaviNet® web portal. Professional providers may perform the following functions as they relate to their practice:

● Add/Delete a participating practitioner to/from an existing practice ● Add/Delete an address (i.e., doing business as [DBA], check, mailing, main, or practice) ● Add/Delete contact name, title, or communication device type/number ● Add/Delete office hours ● Update “Walk-in” acceptance status ● Update Patient and Appointment Options (i.e., accepting new patients) ● Update General Practice Availability (i.e., Urgent, Routine Visits, etc.) ● Update Member Access number (i.e., the telephone number that appears on the member’s identification

card – which must be the location-specific telephone number for a patient to make an appointment) ● Update Electronic Medical Records (EMR) status ● Update the availability of other clinical staff (i.e., midwife, nurse practitioner, etc.) ● Update office accessibility and services (i.e., handicapped, parking, and communication and language

services)

For more information on how to use the Provider File Management transaction, please review the user guide, which is available in the NaviNet Resources section.

The Provider File Management transaction is not intended for use by facilities, skilled nursing facilities, ancillary providers, or providers contracted with Magellan Healthcare, Inc. (Magellan), an independent company.

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If you are unable to process your request through the Provider File Management transaction, please submit a Provider Change Form. Be sure to print clearly, provide complete information, and attach additional documentation as necessary. Mail your completed Provider Change Form to:

Independence Blue Cross Attn: Network Administration P.O. Box 41431 Philadelphia, PA 19101-1431

You can also fax the completed form to Network Administration at 215-238-2275. Please be sure to keep a confirmation of your fax.

Note: The Provider Change Form cannot be used if you are closing your practice or leaving the network. Refer to “Resignation/termination from the Independence network” in the Administrative Procedures section of the Provider Manual for more information regarding these policies and procedures.

Facility and ancillary providersAs outlined in the Administrative Procedures section of the Hospital Manual, Independence requires 30 days advance written notice to process updates to address, phone number, or fax number. Please provide notice to Independence of a change in ownership or control in accordance with the requirements of your Agreement.

Submitting updates and/or changesNotification of all changes must be submitted in writing to both our contracting and legal departments at the following addresses, or as provided in your Agreement:

Independence Blue Cross Attn: Vice President, Total Value Contracting and Reimbursement 1901 Market Street, 27th Floor Philadelphia, PA 19103

Independence Blue Cross Attn: Deputy General Counsel, Managed Care 1901 Market Street, 43rd Floor Philadelphia, PA 19103

Authorizing signature and W-9 FormsUpdates resulting in a change on your W-9 Form (e.g., changes to a provider’s name, tax ID number, billing vendor or “pay to” address, or ownership) require the following signatures:

● For professional providers: − Group practices: A signature from a legally authorized representative (e.g., physician or other person who

signed the Agreement or one who is legally authorized to bind the group practice) of the practice is required. − Solo practitioners: A signature from the individual practitioner is required.

● For facility and ancillary providers: Written notification on company letterhead is required.

An updated copy of your W-9 Form reflecting these changes must also be included to ensure that we provide you with a correct 1099 Form for your tax purposes. If you do not submit a copy of your new W-9 Form, your change will not be processed.

Independence will not be responsible for changes not processed due to lack of proper notice. Failure to provide proper advance written notice to Independence may delay or otherwise affect provider payment.

If you have any questions about updating your provider information, please contact Customer Service at 1-800-ASK-BLUE.

*To ensure appropriate setup in Independence systems, the same time frames also apply to behavioral health providers contracted with Magellan. Behavioral health providers must submit any changes to their practice information to Magellan via their online Provider Data Change form by selecting the “Display/Edit Practice Info” link.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.

Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members.

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IVE New EFT requirement

Published June 29, 2018

Effective January 1, 2019, Independence will be implementing a new electronic funds transfer (EFT) requirement. All participating providers must register for and maintain EFT capability for the payment of claims, capitation, and incentive-based programs. EFT registration enables a direct electronic payment from Independence to your bank account versus mailed check payments that can be lost or take several days to reach you.

Note: This new requirement will be reflected in the Provider Manual for Participating Professional Providers and the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers once the EFT requirement becomes effective.

Registration detailsRegistration for EFT must be completed no later than January 1, 2019, through the NaviNet® web portal by an individual who is authorized to access and maintain banking information for your organization. Note: This individual will be required to attest as the designated responsible party when first accessing the EFT registration screen.

We encourage you to begin the registration process early so that you are compliant by January 1, 2019. You may choose an alternative effective date, but that date may not be later than January 1, 2019.

Please review the detailed EFT Attestation and Registration Guide, which is available in the NaviNet Resources section.

If you currently do not have an account with NaviNet, please call us at 215-640-7410.

Learn moreFor more information on this requirement, please review the EFT requirement: Frequently asked questions (FAQ) document, which can also be found on Independence NaviNet Plan Central in the Frequently Asked Questions section under Administrative Tools & Resources. Note: The FAQ will be updated as more information becomes available.

If you have additional questions or need help with the registration process, please contact the eBusiness Hotline at 215-640-7410.

Updates on this EFT requirement will be communicated in future Partners in Health UpdateSM articles.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.

The benefits of EFTThere are several benefits of using EFT over conventional paper-based methods, including:

● higher security ● faster access to funds ● reduced administrative processing time

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Published June 1, 2018

Effective for dates of service on or after September 1, 2018, Independence Blue Cross and its affiliates (Independence) will be making the following changes:

● updating the standard medical and drug fee schedules for professional providers; ● amending the Professional Provider Agreement to conform with contract language changes to our standard

form Professional Provider Agreement.

To the extent that you are affected by these changes, Independence notified you via a postcard on June 1, 2018.

ResourcesWe have posted the following resources related to the changes listed above on the NaviNet® web portal:

● sample standard medical fee schedules (primary care physician and specialist) based on the most commonly billed CPT® codes by specialty;

● standard professional drug, injectable, and vaccine fee schedule;

● Fee Schedule and Advisory Amendment to your Independence Professional Provider Agreement, as applicable.

To access these documents, go to Independence NaviNet Plan Central and select Resources from the Workflows menu.

If you have questions related to these changes, please email us at the appropriate address — pcprequests@ibx.com or specialistsrequests@ibx.com — with the subject line “Professional Fee Schedule updates.” Make sure to include the practice name, NPI number, and your contact information. You will receive a response within five business days.

Note: This information does not apply to providers contracted with Magellan Healthcare, Inc., an independent company.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members.

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Enhanced claim edits to support correct coding principlesPublished June 11, 2018

Claims received by Independence on or after June 10, 2018, are subject to the new claim editing process during prepayment review to ensure compliance with current industry standards and support the automated application of correct national coding principles.* By applying these principles, we will be consistent with other payers in the region and will apply claim payment principles that are national in scope, simple to understand, and continue to comply with industry standard sources, including:

● Centers for Medicare & Medicaid Services (CMS) standards such as the National Correct Coding Initiative (NCCI), modifier usage, and global surgery guidelines

● American Medical Association (AMA) Current Procedural Terminology (CPT®) coding guidelines ● CMS HCPCS LEVEL II Manual coding guidelines ● ICD-10 Instruction Manual coding guidelines

Please be advised that as guidelines from these sources are updated, our claim edits will be reviewed and additional claim edits will be implemented as applicable.

*Self-funded groups have the option to opt out of the enhanced claim edits; therefore, your outcomes may vary by plan.

Areas of focusIndependence’s correct coding principles will continue to focus on areas such as:

● National bundling edits, including the Correct Coding Initiative (CCI) ● Modifier usage including, but not limited to, the following:

– 26 – 77 – TC– 59 – 78

● Global surgery period ● Add-on code usage

With the implementation of these claim edits, claims submitted with inappropriate coding will be returned or denied. Providers will be notified via the Provider Explanation of Benefits (EOB) (professional) or Provider Remittance (facility), which will include a reason code for the claim return or denial. Any returned claims must be corrected prior to resubmission. These changes should have little or no impact to billing practices for submission of claims that are in accordance with the guidelines listed above and national industry-accepted coding standards.

Claim review requestsWe recognize there may be times when you have questions regarding the outcome of a claim edit. As with all claim review requests, these questions should be submitted using the Claim Investigation transaction on the NaviNet® web portal. Claim lines that have gone through the editor can be identified by the alpha-numeric codes and messages beginning with E8 on your Provider EOB or Provider Remittance. Refer to the box at right for more information.

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Identifying claims that went through the new claim editor processIf your claim was affected by one of the new claim edits, the edit explanation will be displayed on your electronic remittance report (835) and/or paper Provider EOB or Provider Remittance. Unique alpha-numeric codes and messages have been created that begin with E8. Should your claim line contain an E8XXX code/message, it means it was affected by the enhanced claim editor. You can also find the E8XXX codes/messages on the Claim Status Inquiry Detail screen in NaviNet. To view, hover your mouse over the service line and select View Additional Detail. If you see an E8XXX code/message, the line went through an edit. Only E8XXX codes/messages are part of the enhanced claim editor. All other codes/messages are unrelated to the enhanced claim editor.

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For more informationFor questions about the claim editing process, please review our Claim edit enhancements: Frequently asked questions (FAQ), which can also be found on Independence NaviNet Plan Central in the Frequently Asked Questions section under Administrative Tools & Resources. Note: The FAQ will be updated as more information becomes available.

If you still have questions after reviewing the FAQ, please send an email to claimeditquestions@ibx.com.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.

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Automated claim editsHere are some examples of claim edits included in the new claim editing process:

ICD-10 coding ● Excludes 1 Notes: Claim lines reported with mutually exclusive code combinations according to the

ICD-10-CM Excludes 1 Notes will be denied. − When a code from range H73.0 – H73.099 (Acute myringitis) is associated to the same claim line as a

code in either the range H65 − H65.93 (Nonsuppurative otitis media) or the range H66 – H66.93 (Suppurative and unspecified otitis

media), then the claim line will be denied. ● Laterality: The Diagnosis-to-Modifier comparison assesses the lateral diagnosis associated to the claim

line to determine if the procedure modifier matches the lateral diagnosis. If it does not match, the claim line will be denied.

− DIAG1: H60.332 (Swimmer’s ear, left ear) − CPT: 69000 (Drainage external ear, abscess, or hematoma; simple) − MOD: RT

● Primary diagnosis code reporting: Certain diagnosis codes cannot be reported as the only or primary diagnosis code on a claim. If one of the following codes is reported as the only or primary diagnosis, then the claim line will be denied:

− Manifestation codes − External causes (i.e., “V – Y” codes) − Secondary codes (e.g., Z33.1)

Evaluation and Management services ● Only one new patient visit will be allowed to the same group practice and specialty within three years. ● Only one initial inpatient hospital visit and inpatient hospital discharge will be allowed per hospital stay. ● Accurate reporting of initial, subsequent, and observation discharge care.

Surgical services ● Accurate reporting of modifiers for the billing of surgical services rendered by one or more providers. ● Primary surgeon should not also report as the assistant surgeon.

Code combinations ● Vaccine toxoid must be reported on the same day as a vaccine administration. ● Ambulance mileage must be reported on the same day as an ambulance transport.

Procedure/Diagnosis vs. Age consistencyCertain procedure and diagnosis codes are limited to a specific age group. The age groups recognized within our edits are as follows:

● Newborn/Neonatal: < 29 days ● Infant: < 1 year (includes newborn/neonatal) ● Child: 1 – 11 years ● Adolescent: 12 – 17 years ● Pediatric: 0 – 17 years (includes newborn/neonatal, infant, child, and adolescent) ● Adult: 15 years and older ● Maternity: 12 – 55 years ● Geriatric: 70 years and older

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Services eligible for reimbursement above the capitation ratePublished June 12, 2018

At Independence, we are committed to our members’s care. Most medically necessary and preventive services provided to our commercial and Medicare Advantage HMO and POS members by a primary care physician (PCP) are included in the monthly capitation payment. However, some services that can be performed at a PCP’s office (e.g., wart removal or vaccines) are eligible to be paid above the monthly capitation rate.

A complete list of services that are paid over and above the monthly capitation payments (above capitation) is available in Attachments A, B, and C (depending on PCP’s state) in the following Independence policies:

● Commercial: #00.10.01y: Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers

● Medicare Advantage: #MA00.033e: Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers

PCPs are also eligible to receive payment above capitation for codes listed in the injectable drug and vaccine fee schedules.

If you opt to perform these services in your office, be sure to submit the required documentation as noted in the policy.

By using these fee-for-service reimbursements, we can help our members by reducing the need for referrals or specialist visits.

For more informationTo view the above policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and select Commercial or Medicare Advantage from the top of the page and type the policy name or number in the Search field.

Updated payer ID grids now availablePublished June 1, 2018

The professional and facility payer ID grids contain valuable information to assist you in claims submission, including prefixes, payer information, and claims mailing addresses by product.

The grids have recently been updated to reflect an additional prefix for the Third-party administrators product. Please be sure to download the most current versions, which are available on our Electronic Data Interchange (EDI) web page under EDI Resources.

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Pass-through billing not permitted by IndependencePublished June 21, 2018We would like to remind you that Independence does not allow pass-through billing for covered services. In accordance with your Provider Participation Agreement, you may bill Independence only for covered services that you or your staff perform. Participating providers are not permitted to submit claims for services that they have ordered, but they have not rendered (also known as “pass-through” billing). For example, pass-through billing by a physician practice of laboratory services performed by a third-party laboratory is not reimbursable by Independence.

You should use an Independence-contracted laboratory to perform pathology services for Independence members, including both the technical portion and the professional portion of the services.

The laboratory should bill Independence directly for services it performs – they should not attempt to bill your practice for services.

As a reminder, as of April 1, 2018, claims submitted for pathology services that are billed by an office-based pathologist will be denied. However, dermatologists who perform certain pathological procedures in their office (at the time of a patient’s visit) may bill Independence for the service. For more information, refer to the Partners in Health UpdateSM article, Changes for pathologist reporting services in the office setting, published on February 13, 2018.

Reminder: Billing and cost-sharing for individuals enrolled in the Qualified Medicare Beneficiary programPublished June 12, 2018

The Qualified Medicare Beneficiary (QMB) program is a state Medicaid benefit that pays Medicare premiums and cost-sharing for certain low-income Medicare beneficiaries. For enrollees who are eligible for both Medicare and Medicaid, you may bill the state for applicable Medicare cost-sharing. However, such payments are subject to individual state payment limits.

Federal law states that Medicare providers may not collect Medicare Part A and Medicare Part B cost-sharing (i.e., copayments, coinsurance, or deductibles) from those enrolled in the QMB program, regardless of whether the state reimburses the provider in full for the cost-sharing. Therefore, we would like to remind you that when billing Independence for services rendered to these members, you must accept our reimbursement, according to your Agreement with Independence, as payment in full. All Original Medicare and Medicare Advantage providers — not only those who accept Medicaid — must abide by these billing prohibitions. Medicare providers who do not follow these billing prohibitions may be violating their Medicare Provider Agreement and may be subject to sanctions.

Identifying QMB membersOn the NaviNet® web portal, select the Eligibility and Benefits Inquiry transaction from the Independence Workflows menu. Then, from the Eligibility and Benefits Details Screen, select Health Benefit Plan Coverage from the Benefits menu. “QMB MEMBER” will be indicated within the Co-Insurance and Out-of-Pocket Max sections. The QMB indicator will also be returned through the EDI 271 transaction.

In addition, providers are reminded that discrimination against beneficiaries based on their payment status is prohibited.

To learn more, read the updated Prohibition Billing Dually Eligible Individuals Enrolled in the QMB Program article on the Centers for Medicare & Medicaid Services’ website.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.

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ICD-10 in Action: Coding guidelines and conventions – Excludes1 and Excludes2 notesPublished June 22, 2018

This Independence series, ICD-10 in Action, features articles to recap some of the ICD-10 diagnosis code changes, introduce new coding scenarios, and/or communicate updates to ICD-10 coding conventions.

The ICD-10-CM Manual contains official guidelines for coding and reporting. There are coding conventions, general coding guidelines, and chapter-specific guidelines. These conventions and guidelines are rules and instructions that must be followed to classify and assign the most appropriate code. Understanding these guidelines and conventions are key to selecting the most appropriate code assignment.

● Conventions. A set of rules for use of the classification independent of the guidelines. Coding conventions and instructions of the classification take precedence over guidelines. (e.g., Code First).

● General guidelines. A set of rules and sequencing instructions for using the Tabular List and Alphabetic Index. These guidelines provide rules such as how to locate a code and obtain level of detail.

● Chapter-specific guidelines. A set of rules for specific diagnoses and conditions in a particular classification.

As with ICD-9, adherence to these guidelines is required under the Health Insurance Portability and Accountability Act (HIPAA).

Coding Convention – Excludes NotesAccording to the ICD-10-CM Official Guidelines for Coding and Reporting, there are two types of excludes notes, Excludes1 and Excludes2. Each type has a different definition for use, but they are both similar in that they indicate that codes excluded from each other are independent of each other.

Excludes1Excludes1 is a pure excludes note. It means “NOT CODED HERE.” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 note is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, request clarity from the provider. For example, code F45.8, Other somatoform disorders, has an Excludes1 note for “sleep related teeth grinding (G47.63),” because “teeth grinding” is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding. However, psychogenic dysmenorrhea is also an inclusion term under F45.8. A patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are clearly unrelated to each other. It would be appropriate to report F45.8 and G47.63 together.

Excludes2Excludes2 represents “NOT INCLUDED HERE.” An Excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

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Stay tunedWe will continue to communicate ICD-10-specific information through this article series to review some of the ICD-10 diagnosis code changes. We encourage you to keep up with the latest news and information by visiting the ICD-10 section of our website.

Coding examplesExcludes1 and Excludes2 Notes1. A15.4 – Tuberculosis of intrathoracic lymph nodes

Excludes1: A15.7 – Primary respiratory tuberculosis Excludes1: P37.0 – Congenital tuberculosis

2. A18.6 – Tuberculosis of (inner) (middle) ear Excludes2: A18.4 – Tuberculosis of skin and subcutaneous tissue Note: A18.4 represent tuberculosis of external ear

3. C79.2 – Secondary malignant neoplasm of skin Excludes1: C7B.1 – Secondary Merkel cell carcinoma Note: C7B.1 is a type of skin cancer. The more specific code should be used.

4. C79.51 – Secondary malignant neoplasm of bone Excludes1: C7B.03 – Secondary carcinoid tumors of bone

5. D24.1 – Benign neoplasm of right breast Excludes2: D22.5 – Melanocytic nevi of trunk Excludes2: D23.5 – Other benign neoplasm of skin of trunk Note: D22.5 and D23.5 represent benign neoplasm of the skin of the breast.

6. D29.1 – Benign neoplasm of prostate Excludes1: N40.0 – Benign prostatic hyperplasia without lower urinary tract symptoms Excludes1: N40.1 – Benign prostatic hyperplasia with lower urinary tract symptoms Excludes1: N40.2 – Nodular prostate without lower urinary tract symptoms Excludes1: N40.3 – Nodular prostate with lower urinary tract symptoms Note: The range of N40._ _ – Represent enlarged prostate

7. E36.01 – Intraoperative hemorrhage and hematoma of an endocrine system organ or structure complicating an endocrine system procedure Excludes1: E36.11 – Accidental puncture and laceration of an endocrine system organ or structure during an endocrine system procedure Excludes1: E36.12 – Accidental puncture and laceration of an endocrine system organ or structure during other procedure

8. F05 – Delirium due to known physiological condition Excludes1: R41.0 – Disorientation, unspecified Excludes2: F10.231 – Alcohol dependence with withdrawal delirium Excludes2: F10.921 – Alcohol use, unspecified with intoxication delirium Note: R41.0 represent delirium NOS, F10.231 and F10.921 represent alcohol induced delirium tremens.

9. G44.41 – Drug-induced headache, not elsewhere classified, intractable Excludes1: R51 – Headache Excludes2: G97.1 – Other reaction to spinal and lumbar puncture Note: G97.1 may represent headache due to lumbar puncture.

10. H05.30 – Unspecified deformity of orbit Excludes1: Q10.7 – Congenital malformation of orbit Note: This is a case of the acquired versus the congenital form of the same condition. This can never be reported together.

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Reminder: Billing guidelines for BlueCard® claims for lab, DME, and specialty pharmacy providersPublished June 22, 2018

BlueCard is a national program offered through the Blue Cross and Blue Shield Association (BCBSA), an association independent of Blue Cross® and Blue Shield® plans, that enables members of one Blue Plan to obtain health care benefits and services while traveling or living in another Blue Plan’s service area. The BlueCard program provides coverage for members by linking participating health care providers through a single electronic network for claims processing and reimbursement. This extensive network provides coverage to members travelling in the U.S. and in approximately 170 countries and territories worldwide.

Standardized claims filing guidelines were implemented in 2012 for independent clinical laboratories (lab), durable medical equipment (DME) providers, and specialty pharmacies.

Note: These billing guidelines do not apply to claims submitted for Federal Employee Program (FEP®) members. For more information about FEP claims filing guidelines, please refer to the FEP website.

Ancillary providers contracted with IndependenceLab (non-hospital based):

Example: ● If an Independence member has a specimen drawn and the referring provider is contracted with

Independence, the lab provider must file the claim with Independence. ● If a BlueCard member has a specimen drawn in the five-county Philadelphia region, the lab provider must file

the claim with Independence. ● If a BlueCard member has a specimen drawn outside the five-county Philadelphia region, the lab provider must

file the claim with the Plan local to the area in which the specimen was drawn.

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How to file (required fields) Where to fileReferring Provider:

● Field 17 with qualifier DN on CMS-1500 form, or ● Loop 2310A (claim level) on 837P (Professional

Electronic Submission)

File the claim with the Plan local to the area in which the specimen was drawn. For states with multiple Blue Plans, the state or county in which the referring provider is located will determine where the specimen is drawn.

How to file (required fields) Where to file

Patient’s Address: ● Field 5 on CMS-1500, or ● Loop 2010CA on 837P

Ordering Physician: ● Field 17 with qualifier DK on CMS-1500, or ● Loop 2420E (line level) on 837P

Place of Service: ● Field 24B on CMS-1500, or ● Loop 2300, CLM05-1 on 837P

Service Facility Location Information: ● Field 32 on CMS-1500, or ● Loop 2310C (claim level) on 837P

File the claim with the Plan local to the service area in which the DME supplies were shipped or received.

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Example: ● For an Independence member, the DME supplier must file the claim with Independence regardless of where

DME supplies were shipped or received. ● If a BlueCard member has DME supplies shipped to or received at a location in the five-county Philadelphia

region, the DME supplier must file the claim with Independence. ● If a BlueCard member has DME supplies shipped to or received in a location outside the five-county

Philadelphia region, the DME supplier must file the claim with the Plan local to the area in which the DME supplies were shipped or received.

Specialty Pharmacy (non-routine, biological therapeutics ordered by a health care professional as a covered medical benefit as defined by the Plan’s Specialty Pharmacy formulary):

Example: ● For an Independence member, regardless of where the referring (ordering) physician is located, the specialty

pharmacy provider must file the claim with Independence. ● If a BlueCard member uses a specialty pharmacy and the referring (ordering) physician is in the five-county

Philadelphia region, the specialty pharmacy provider must file the claim with Independence. ● If a BlueCard member uses a specialty pharmacy and the referring (ordering) physician is outside of the five-

county Philadelphia region, the specialty pharmacy provider must file the claim with the Plan local to the area of the ordering physician.

Ancillary providers who are not contracted with Independence or any other Blue PlanLab: For Independence or any other BlueCard member, the lab provider must file the claim with the Plan local to the service area in which the specimen was drawn.

DME: For Independence or any other BlueCard member, the DME supplier must file the claim with the Plan local to the service area in which the DME supplies were shipped or received.

Specialty Pharmacy: For Independence or any other BlueCard member, the specialty pharmacy provider must file the claim with the Plan local to the referring (ordering) physician’s service area.

Note: The claim is considered a nonparticipating provider claim since the ancillary provider does not have a contract with Independence or any other Blue Plan.

Ancillary providers contracted with a Blue Plan other than IndependenceIf you are contracted with a Blue Plan other than Independence, always file claims with that Blue Plan for services rendered to that Plan’s enrollees. In addition, you should file claims for services rendered to any other BlueCard member in your contracted Blue Plan’s service area to that Blue Plan. For example, a provider contracted with Horizon Blue Cross and Blue Shield (Horizon) should file claims for a BlueCard member with Horizon.

Lab:File claims for any other BlueCard member with Horizon for specimens drawn in New Jersey.

DME: File claims for any other BlueCard member with Horizon for DME supplies shipped to or received in New Jersey.

How to file (required fields) Where to fileReferring Provider:

● Field 17B on CMS-1500 form, or ● Loop 2310A (claim level) on 837P

For states with multiple Blue Plans, file the claim with the Plan local to the state or county of the ordering physician.

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Specialty Pharmacy: File claims for any other BlueCard member with Horizon when the referring (ordering) physician is located in New Jersey.

If services are rendered to Blue Plan members who are not enrolled with your contracted Blue Plan, or for services rendered outside your contracted Blue Plan’s service area, you should file claims according to the guidelines listed below. These claims will be considered nonparticipating claims.

Lab:File claims with the Plan local to the service area in which the specimen was drawn.

DME:File claims with the Plan local to the service area in which the DME supplies were shipped or received.

Specialty Pharmacy:File claims with the Plan local to the ordering physician’s service area.

More informationFor more information about the BlueCard Program, visit the BlueCard section.

Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.

New medical record retrieval coordinator for ACA programsPublished June 21, 2018

Independence is pleased to announce that effective January 1, 2018, Inovalon, an independent company, was selected to retrieve medical records for out-of-area Blue members. Inovalon will coordinate medical record requests from Blue Cross® and Blue Shield® companies across the country and help reduce multiple requests for patient data. This arrangement supports Healthcare Effectiveness Data and Information (HEDIS®), risk adjustment, and government-required programs related to the Affordable Care Act (ACA).

Requests for medical recordsAs outlined in your contract, you are required to respond to requests in support of risk adjustment, HEDIS, and other government-required activities within the requested time frame. This includes requests from Inovalon on our behalf. Independence is working diligently to make this process as simple as possible.

For your convenience, medical records may be submitted to Inovalon using any of the following methods: ● Fax. Fax medical records to 1-877-221-0604. ● FedEx®. For further instruction on returning medical records via FedEx, please call 1-800-463-3339. ● Email. Send medical records via secure email to EMRService@inovalon.com.

If you have questions on delivery options and methods, call Inovalon at 1-844-682-9764.

HIPAA and privacyInovalon is contractually bound to preserve the confidentiality of health plan members’ protected health information (PHI) obtained from medical records, in accordance with Health Insurance Portability and Accountability Act (HIPAA) regulations. Please note that patient-authorized information releases are not required for you to comply with these requests for medical records.

Providers are permitted to disclose PHI to health plans without authorization from the patient when both the provider and health plan have a relationship with the patient and the information relates to the relationship.

For more information regarding privacy rule language, please visit the U.S. Department of Health & Human Services website.

Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Used with permission.

June 2018 | Partners in Health UpdateSM 18 www.ibx.com/pnc

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SRegistered Nurse Health Coaches: Supporting providers and patientsPublished June 19, 2018

Independence recognizes that the physician-patient relationship is at the heart of patient care. Registered Nurse Health Coaches can assist your practice and help provide coordination of care for your Independence patients. We provide information for patients, their families, and physicians, as well as share community resources.

If you would like to refer an Independence patient to or speak with a Registered Nurse Health Coach, complete the online physician referral form or call 1-800-313-8628.

Independence patients who are covered through fully insured employer groups are automatically considered eligible for condition management. Patients covered through certain self-insured employer groups may not be eligible for the program. Patients can call Customer Service at 1-800-ASK-BLUE to verify their eligibility.

Coordination of careOur highly skilled Registered Nurse Health Coaches and licensed Social Workers are available to support your practice in a variety of ways, including:

● providing patients with education about managing a new or chronic condition; ● educating patients on the importance of medication and plan-of-care adherence; ● supporting patients post-discharge; ● assisting with closing gaps in care; ● reporting medication discrepancies and patients’ needs that are otherwise unreported, such as the need

for potential home care; ● coordinating community resources not covered by insurance, such as medication assistance,

transportation services, food resources, and home modification programs; ● assisting patients in making appointments; ● encouraging patients to discuss concerns and questions with their health care provider(s); ● educating patients about shared decision-making, which leads to improved adherence to treatment plans.

Reminder: Updates to the list of specialty drugs that require precertificationPublished June 15, 2018

As of June 15, 2018, the following specialty drugs, which are eligible for coverage under the medical benefit, now require precertification for Independence commercial and Medicare Advantage HMO and PPO members:

● Crysvita® (burosumab-twza) ● IlumyaTM (tildrakizumab-asmn) ● TrogarzoTM (ibalizumab-uiyk)

Note: Independence’s medical policies for these drugs are currently in development. Until these policies are published, precertification review for these drugs will be based on the U.S. Food and Drug Administration (FDA)-approved indication.

In addition, the following drugs are currently pending approval from the FDA. These drugs will require precertification from Independence once they receive FDA approval:

● a biosimilar for the drug Soliris® (eculizumab) ● the anti-PD-1 monoclonal antibody cemiplimab

These changes are reflected in an updated precertification requirement list, which has been posted to our website.

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Site of service changes and new coverage option for Benlysta® now in effectPublished June 1, 2018

The U.S. Food and Drug Administration (FDA) recently approved a subcutaneous formulation of Benlysta (belimumab) for the treatment of active, autoantibody-positive systemic lupus erythematosus. This is the second formulation of Benlysta to receive FDA approval; the infusible formulation was approved in 2011. The subcutaneous formulation allows members to self-administer the drug at home rather than go to a hospital outpatient facility for infusion.

As of June 1, 2018, Independence added the infusible formulation of Benlysta to our Most Cost-Effective Setting Program for members enrolled in commercial products. This formulation remains eligible for coverage under the medical benefit, but the following changes occurred:

● New requests for infusible Benlysta now require review for setting, as well as medical necessity, during the precertification process.

● Members who have received precertification approval for infusible Benlysta in a hospital outpatient facility may continue treatment in this setting until their current precertification approval expires. However, at the next precertification review, Independence will evaluate the requested setting and make a coverage determination.

Appropriate setting reviewDuring precertification review, each member’s medical needs and clinical history are evaluated to determine if the drug requested by the provider is appropriate. As part of our Most Cost-Effective Setting Program, Independence also reviews the requested treatment setting for certain drugs covered under the medical benefit to ensure that they are administered in settings that are both safe and cost-effective.

Covered settings for infusible Benlysta include: ● a physician’s office; ● the member’s home, where the infusion is

administered by an in-network home infusion provider; ● an ambulatory (freestanding) infusion suite that is not owned by a hospital or health system in our network.

Drugs included in the Most Cost-Effective Setting ProgramThe following is a complete list of drugs that will require precertification approval for medical necessity and setting as of June 1, 2018:*

● Actemra® (tocilizumab) ● Aralast NP® (alpha-1 proteinase inhibitor [human]) ● Benlysta® (belimumab) – NEW AS OF JUNE 1, 2018 ● Cerezyme® (imiglucerase) ● ElelysoTM (taliglucerase alfa) ● Entyvio® (vedolizumab) ● Exondys-51TM (eteplirsen) ● Fabrazyme® (agalsidase beta) ● Glassia® (alpha-1 proteinase inhibitor [human]) ● Inflectra® (infliximab-dyyb) ● Intravenous/subcutaneous immunoglobulin (IVIG/SCIG) ● IxifiTM (infliximab-qbtx) ● Lumizyme® (alglucosidase alfa) ● Neulasta® (pegfilgrastim) ● Neulasta® (pegfilgrastim) Onpro®

● Nucala® (mepolizumab) ● OcrevusTM (ocrelizumab) ● Orencia® (abatacept) ● Prolastin® (alpha-1 proteinase inhibitor [human]) ● Prolia® (denosumab) ● RadicavaTM (edaravone) ● Remicade® (infliximab) ● Renflexis® (infliximab-abda) ● Sandostatin® LAR Depot (octreotide acetate) ● Simponi Aria® (golimumab) ● Soliris® (eculizumab) ● Somatuline® Depot (lanreotide) ● Stelara® (ustekinumab) ● Vimizim® (elosulfase alfa) ● VPRIV® (velaglucerase alfa) ● Xolair® (omalizumab) ● Zemaira® (alpha-1 proteinase inhibitor [human])

*This list of drugs is subject to change.

Note: All biosimilars to the originator products in this program are subject to precertification review for most cost-effective setting.

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commercial membersCovering infusible Benlysta under the medical benefit and subcutaneous Benlysta under the pharmacy benefit gives our commercial members more treatment options. Members whose pharmacy benefits are managed by FutureScripts®, our independent pharmacy benefits manager, can choose to receive subcutaneous Benlysta under their pharmacy benefit. Providers are encouraged to consider the subcutaneous formulation for patients who may be interested in self-administering the drug. Providers will need to write new prescriptions for members who choose to receive subcutaneous Benlysta. Note: The subcutaneous formulation of Benlysta is not covered under the medical benefit.

A hospital outpatient facility setting will primarily be considered for members who are receiving an initial dose of Benlysta or if there is a clinical rationale that requires the member to receive treatment in that setting. The provider must submit documentation to Independence to support the request for coverage in the hospital outpatient facility. This information will be reviewed and a coverage determination on setting will be made.

FutureScripts is an independent company that provides pharmacy benefits management services.

Updates to Direct Ship Drug Program request formsPublished June 11, 2018

The Independence Direct Ship Drug Program is a service that allows our network providers to order select office-based drugs eligible for coverage under the medical benefit without paying an additional fee. Independence works directly with our specialty drug vendors to handle processing, payment, and delivery.

Direct ship drug request form updatesWe have updated the general drug request form, which is used to request all direct ship drugs that do not have a specific order form.

In addition, updates have been made to the following five direct ship request forms for specific drugs, which reflect new medical policy criteria or new formulation options:

● Hydroxyprogesterone Caproate ● Nucala® (mepolizumab) ● Stelara® (ustekinumab) ● Viscosupplementation (hyaluronate acid products) (Orthovisc®, Synvisc®, Synvisc-One®, Euflexxa®, Gel-One®,

GelSyn-3TM, GenVisc 850®, Hyalgan®, Hymovis®, Monovisc®, Supartz®, VISCO-3TM, Durolane®, and TriViscTM) ● Xolair® (omalizumab)

If your office has previous versions of these forms, please discard them and use the updated forms, which are available for download on our website and can be identified by the April 2018 date at the bottom-right corner.

New direct ship drug request formsNew forms have been created for the following drugs:

● Vivitrol® (naltrexone) ● FasenraTM (benralizumab)

These forms are available for download on our website. Please add these new direct ship request forms to your office’s form library.

For more informationFor more information on the Direct Ship Drug Program, including the list of medical benefit drugs available under this program or to download the forms, go to our website.

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Updated information regarding our Cardiology Utilization Management ProgramPublished June 11, 2018

We previously notified you about new utilization management requirements for our Cardiology Utilization Management Program that includes cardiovascular tests/diagnostic procedures and nonsurgical treatments for obstructive coronary artery disease. Utilization management review for these services is delegated to AIM Specialty Health® (AIM), an independent company, for all Independence members.

Please note that the following services/Current Procedural Terminology (CPT®) codes will be reviewed post-service in accordance with AIM’s clinical criteria:

● Duplex Scan Lower Extremity Arteries – Must be reported to AIM prior to claims submission and within ten business days following physiologic testing for peripheral artery disease (PAD). The physiologic test results must be available when contacting AIM.

− 93925 − 93926

● Duplex Scan Upper Extremity Arteries – Must be reported to AIM prior to claims submission and within ten business days following physiologic testing for PAD. The physiologic test results must be available when contacting AIM.

− 93930 − 93931

● Percutaneous Coronary Intervention (PCI) – Must be reported to AIM prior to claims submission and within ten business days following diagnostic coronary angiography. The diagnostic coronary angiography results and relevant clinical information must be available when contacting AIM.

− 92920, 92921 − 92924, 92925 − 92928, 92929 − 92933, 92934 − 92937, 92938 − 92943, 92944

Exception: When the results of the coronary angiogram are known and the coronary angiogram and PCI are not performed at the same time, precertification/preapproval of the PCI must be obtained prior to the service being performed.

If you have any questions, please send an email to aim_umprograms@ibx.com.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

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Reminder: Changes to reimbursement of consultation codes for Medicare Advantage HMO and PPO membersPublished June 4, 2018

As a reminder, effective August 1, 2018, Independence will update its reimbursement position on the Current Procedural Terminology (CPT®) codes used to report consultation services provided to Independence’s Medicare Advantage HMO and PPO members.

Based on a review of the Centers for Medicare & Medicaid Services (CMS) standards, Independence has created Medicare Advantage policy #MA00.049: Consultation Services, which outlines its reimbursement position on CPT consultation codes. This new policy was posted as a Notification on May 3, 2018, and will go into effect August 1, 2018.

The policy states that Independence will align with CMS’s position of no longer recognizing the following CPT consultation codes as eligible for reimbursement:

● 99241 ● 99251 ● 99242 ● 99252 ● 99243 ● 99253 ● 99244 ● 99254 ● 99245 ● 99255

When rendering services to Independence Medicare Advantage HMO and PPO members, all providers should report the appropriate level of evaluation and management (E&M) service in lieu of consultation codes.

Affected policiesThis change to our reimbursement position for CPT consultation codes used to report consultation services also affects our Medicare Advantage policies on preoperative anesthesia consultations and Modifier 25 as outlined below.

Changes to the following Medicare Advantage policies, which were posted as Notifications on May 3, 2018, will go into effect August 1, 2018:

● #MA01.002: Preoperative Consultations Performed by Providers in Anesthesia Specialties: This policy will be archived, and anesthesia providers should report the CPT codes that represent the most appropriate level of E&M service.

● #MA03.003d: Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: The following CPT codes will be removed from this policy and will no longer be eligible for reimbursement:

− 99241, 99242, 99243, 99244, and 99245

More informationTo view the Notifications for these policies, visit our Medical Policy Portal and select Accept and Go to Medical Policy Online. Then select Medicare Advantage under Active Notifications.

For questions about this policy, please review our Reimbursement position for consultation codes: Frequently Asked Questions (FAQ), which can also be found on Independence NaviNet® Plan Central in the Frequently Asked Questions section under Administrative Tools & Resources. Note: The FAQ will be updated as more information becomes available.

If you still have questions after reviewing the FAQ, email us at consultcodes@ibx.com. Be sure to include your name, contact number, and provider ID number in your email.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.

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Updated policies on SCODIPublished June 13, 2018

Independence is updating our policies on scanning computerized ophthalmic diagnostic imaging (SCODI) to reflect changes in medical necessity criteria and the covered diagnosis codes.

The following policies were posted as Notifications on the Medical Policy Portal on June 13, 2018, and will go into effect September 10, 2018:

● Commercial: #07.13.06k: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

● Medicare Advantage: #MA07.004d: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

Medical Necessity criteriaAs part of the update, medical necessity criteria for SCODI are being amended as follows:

● The conditions covered for anterior segment evaluation will include specified forms of glaucoma and certain disorders of the cornea, iris, and ciliary body.

● The conditions covered for posterior segment evaluation will include conditions affecting the optic nerve (e.g., optic neuropathy) or retinal disease (e.g., macular degeneration, diabetic retinopathy) and certain macular abnormalities (e.g., macular edema, atrophy associated with degenerative retinal diseases).

● The covered retinal conditions in active treatment, for which one exam, per eye, per month may be appropriate, will include wet age-related macular degeneration (AMD), choroidal neovascularization, macular edema, diabetic retinopathy (proliferative and nonproliferative), branch retinal vein occlusion, central retinal vein occlusion, and cystoid macular edema.

● The timing of monitoring individuals being treated with chloroquine (CQ) and/or hydroxychloroquine (HCQ) will be changed to align with the U.S. Food and Drug Administration labeling.

− Baseline examination will be within the first year of treatment and as an annual follow-up after five years of treatment. For higher-risk individuals, annual testing may begin immediately (without a five-year delay).

Diagnosis codesThe diagnosis codes representing covered conditions for SCODI are being updated in the ICD-10 Diagnosis Code Number(s) and Narrative(s) section of the coding table.

For more informationTo view the Notifications for these policies, visit our Medical Policy Portal and select Accept and Go to Medical Policy Online. Then select Commercial or Medicare Advantage under Active Notifications.

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Updated coverage positions on zoster and hepatitis B vaccines for commercial membersPublished June 18, 2018

Independence has updated our commercial coverage positions for Shingrix, a recombinant, adjuvanted zoster vaccine, and Heplisav-B, a recombinant, adjuvanted hepatitis B vaccine, in accordance with recent recommendations from the Advisory Committee on Immunization Practices (ACIP). Shingrix and Heplisav-B were approved by the U.S. Food and Drug Administration (FDA) in 2017. These changes to our commercial coverage positions were communicated on the Medical Policy Portal in an updated news article Zoster and Hepatitis B Vaccines Approved by the U.S. Food and Drug Administration and Advisory Committee on Immunization Practices (Revised 05/30/2018).

Note: Medicare Advantage members should refer to their Medicare Part D benefit for the coverage position for Shingrix. Medicare Advantage members should refer to their Medicare Part B benefit for the coverage position for Heplisav-B.

BackgroundThe following outlines the history related to the FDA approval and ACIP recommendations for these vaccines:

● Shingrix: On October 23, 2017, the FDA approved Shingrix (Zoster Vaccine Recombinant, Adjuvanted) for the prevention of herpes zoster (shingles) in individuals ages 50 years and older. According to the FDA-approved label, Shingrix (Zoster Vaccine Recombinant, Adjuvanted) is not indicated for prevention of primary varicella infection (chickenpox). On January 26, 2018, the ACIP released its final recommendations for Shingrix (Zoster Vaccine Recombinant, Adjuvanted), which states, “On October 25, 2017, the ACIP recommended the recombinant zoster vaccine (RZV) for use in immunocompetent adults ages 50 years and older.” Shingrix is recommended for the prevention of herpes zoster and related complications for immunocompetent adults who previously received the zoster vaccine live. According to the ACIP, Shingrix is preferred over Zostavax.

● Heplisav-B: On November 11, 2017, the FDA approved Heplisav-B (Hepatitis B Vaccine Recombinant, Adjuvanted) for the prevention of infection caused by all known subtypes of the hepatitis B virus in individuals ages 18 years and older.

On April 20, 2018, the ACIP released their final recommendations for Heplisav-B (Hepatitis B Vaccine Recombinant, Adjuvanted), which states, “On February 21, 2018, the ACIP recommended Heplisav-B (HepB-CpG), a yeast-derived vaccine prepared with a novel adjuvant, administered as a two-dose series (zero, one month) for use in persons ages 18 years and older.”

Coverage statementThe following outlines Independence’s coverage of these vaccines for commercial members:

● Shingrix: Effective October 25, 2017, Shingrix (Zoster Vaccine Recombinant, Adjuvanted) is covered as a preventive service. The two-dose regimen is administered two to six months apart for the prevention of herpes zoster in immunocompetent individuals ages 50 years and older.

● Heplisav-B: Effective February 21, 2018, Heplisav-B (Hepatitis B Vaccine Recombinant, Adjuvanted) is covered as a preventive service. The two-dose regimen is administered one month apart for the prevention of infection caused by all known subtypes of hepatitis B virus in individuals 18 years of age and older.

CodingUse the following codes to represent these vaccines:

● Shingrix: 90750 ● Heplisav-B: 90739

For more informationThe coverage information in the news article Zoster and Hepatitis B Vaccines Approved by the U.S. Food and Drug Administration and Advisory Committee on Immunization Practices (Revised 05/30/2018) will be incorporated into the following commercial policies accordingly:

● #00.06.02u: Preventive Care Services ● #08.01.04r: Immunizations

To view the news article and these policies, visit our Medical Policy Portal and select Accept and Go to Medical Policy Online. Then select Commercial and type the article title, policy name, or policy number in the Search field.

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Four drugs to be added to Most Cost-Effective Setting ProgramPublished June 25, 2018

Independence seeks to ensure that our members receive injectable/infusion therapy drugs in a setting that is both safe and cost-effective. Since 2012, Independence has been reviewing the most appropriate setting for commercial members to receive certain injectable and infusion therapy drugs as part of the precertification review process.

As of June 25, 2018, Independence added the biosimilar FulphilaTM (pegfilgrastim-jmdb) to our Most Cost-Effective Setting Program for members enrolled in commercial products.

In addition, effective October 1, 2018, Independence will add the following drugs to this program for members enrolled in commercial products:

● Adagen® (pegademase bovine) ● Crysvita® (burosumab-twza) ● Naglazyme® (galsulfase)

New requests for these four drugs will require review for setting, as well as medical necessity, during the precertification process.

Members who have precertification approval to receive these drugs in a hospital outpatient facility may continue treatment in this setting until their current precertification approval expires. At the next precertification review, Independence will evaluate the requested setting and make a coverage determination.

Appropriate setting reviewDuring precertification review, each member’s medical needs and clinical history are evaluated to determine if the drug requested by the provider is appropriate. As part of our Most Cost-Effective Setting Program, Independence also reviews the requested treatment setting for certain drugs covered under the member’s medical benefit to ensure that they are administered in settings that are both safe and cost-effective.

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Drugs included in the Most Cost-Effective Setting ProgramThe following is a complete list of drugs that require precertification approval for medical necessity and setting:*

● Actemra® (tocilizumab) ● Adagen® (pegademase bovine) – NEW FOR OCTOBER 1, 2018 ● Aralast NP® (alpha-1 proteinase inhibitor [human]) ● Benlysta® (belimumab) ● Cerezyme® (imiglucerase) ● Crysvita® (burosumab-twza) – NEW FOR OCTOBER 1, 2018 ● ElelysoTM (taliglucerase alfa) ● Entyvio® (vedolizumab) ● Exondys-51TM (eteplirsen) ● Fabrazyme® (agalsidase beta) ● FulphilaTM (pegfilgrastim-jmdb) – NEW FOR JUNE 25, 2018 ● Glassia® (alpha-1 proteinase inhibitor [human]) ● Inflectra® (infliximab-dyyb) ● Intravenous/subcutaneous immunoglobulin (IVIG/SCIG) ● IxifiTM (infliximab-qbtx) ● Lumizyme® (alglucosidase alfa) ● Naglazyme® (galsulfase) – NEW FOR OCTOBER 1, 2018 ● Neulasta® (pegfilgrastim) ● Neulasta® (pegfilgrastim) Onpro®

● Nucala® (mepolizumab) ● OcrevusTM (ocrelizumab) ● Orencia® (abatacept) ● Prolastin® (alpha-1 proteinase inhibitor [human]) ● Prolia® (denosumab) ● RadicavaTM (edaravone) ● Remicade® (infliximab) ● Renflexis® (infliximab-abda) ● Sandostatin® LAR Depot (octreotide acetate) ● Simponi Aria® (golimumab) ● Soliris® (eculizumab) ● Somatuline® Depot (lanreotide) ● Stelara® (ustekinumab) ● Vimizim® (elosulfase alfa) ● VPRIV® (velaglucerase alfa) ● Xolair® (omalizumab) ● Zemaira® (alpha-1 proteinase inhibitor [human])

*This list of drugs is subject to change.

Note: All biosimilars to the originator products in this program are subject to precertification review for most cost-effective setting

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Covered settings for drugs in this program include: ● a physician’s office; ● the member’s home, where the infusion is administered by an in-network home infusion provider; ● an ambulatory (freestanding) infusion suite that is not owned by a hospital or health system in our network.

A hospital outpatient facility setting will primarily be considered for members who are receiving an initial dose of any drug in this program, or if there is a clinical rationale that requires the member to receive treatment in that setting. The provider must submit documentation to Independence to support the request for coverage in the hospital outpatient facility. This information will be reviewed and a coverage determination on setting will be made.

Medical policy informationYou can find additional information about these drugs in the following Independence commercial medical policies:

● #08.00.70c: Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, ElapraseTM, VimizimTM, Naglazyme®, MepseviiTM, etc.)

● #08.01.26: Pegademase bovine (Adagen®)

Note: Medical policies for Crysvita and Fulphila are currently in development. Until these policies are published, precertification review for these drugs will be based on the U.S. Food and Drug Administration (FDA)-approved indication.

To review the medical policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, then select Commercial, and type the policy name or number in the Search field.

View up-to-date policy activity on our Medical Policy PortalPublished June 18, 2018

Changes to Independence medical and claim payment policies for our commercial and Medicare Advantage Benefit Programs occur in response to industry, medical, and regulatory changes. We encourage you to view the Site Activity section of our Medical Policy Portal to stay up to date with changes to our policies.

The Site Activity section is updated in real time as changes are made to the medical and claim payment policies. Topics include:

● Notifications ● New Policies ● Updated Policies ● Reissued Policies ● Coding Updates ● Archived Policies

For your convenience, the information provided in Site Activity can be printed to keep a copy on hand as a reference.

To access the Site Activity section, go to our Medical Policy Portal and select Accept and Go to Medical Policy Online. From there you can select Commercial or Medicare Advantage under Site Activity to view the monthly changes. To search for active policies, select either the Commercial or Medicare Advantage tab from the top of the page. To access policies from Independence NaviNet® Plan Central, select Medical Policy Portal under Provider Tools in the right-hand column.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.

News and AnnouncementsIn addition to the information posted in our Site Activity section, articles related to our website and medical and claim payment policies are periodically posted within the News & Announcements section. Simply select the appropriate link (Commercial, Medicare Advantage, or MAPPO Host) under the News & Announcements header on the Medical Policy Portal home page to stay informed.

Recently published News and Announcements include: Zoster and Hepatitis B Vaccines Approved by the US Food and Drug Administration and Advisory Committee on Immunization Practices (Revised 05/30/2018) (Commercial only).

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ESUpdate your provider record with the NaviNet® Provider File Management transaction Published June 21, 2018

As a reminder, the Provider File Management transaction on the NaviNet web portal allows professional providers to view and submit specific updates to their Independence provider record.

Note: The Provider File Management transaction is not intended for use by facilities, skilled nursing facilities, ancillary providers, or providers contracted with Magellan Healthcare, Inc. (Magellan)*, an independent company.

Professional providers can initiate the following updates as it relates to their practice:

● Add/Delete a participating practitioner to/from an existing practice

● Add/Delete an address (i.e., doing business as [DBA], check, mailing, main, or practice)

● Add/Delete contact name, title, or communication device type/number

● Add/Delete office hours ● Update “Walk-in” acceptance status ● Update Patient and Appointment Options (i.e.,

accepting new patients) ● Update General Practice Availability (i.e., Urgent,

Routine Visits, etc.) ● Update Member Access number (i.e., the telephone

number that appears on the member’s identification card – which must be the location-specific telephone number for a patient to make an appointment)

● Update Electronic Medical Records (EMR) status ● Update the availability of other clinical staff (i.e.,

midwife, nurse practitioner, etc.) ● Update office accessibility and services (i.e.,

handicapped, parking, and communication and language services)

Additional tips to help you update your practice information:

● All practice addresses should be located within the same state.

● Providers that participate in a delegated arrangement must be credentialed by Independence before joining a non-delegated practice.

● It is important that the credentialing status of the practitioner is verified with Independence prior to adding a physician to a practice. If a practitioner who is not participating with Independence is added to a practice, consequences including claim denials, inaccurate reimbursement, and immediate removal from the provider directories may be imposed.

● Closed Networks. There are limitations to participation for the Pathology, Podiatry, and Chiropractic Networks. For additional information, please review the Closed Networks section of our Professional Provider Credentialing webpage.

More informationA Provider File Management Guide is available to assist you in navigating this transaction and ensure accurate submissions. The guide is available in the NaviNet Resources section. If you have any further questions on this transaction, please contact the eBusiness Hotline at 215-640-7410.

*Behavioral health providers must submit any changes to their practice information to Magellan via their online Provider Data Change form by selecting the “Display/Edit Practice Info” link.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.

Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members.

Important information for PCPsThe following functions are not available to primary care physician (PCP) practices due to possible impacts to capitation and/or incentive programs:

● Add/Delete an address (i.e., DBA, check, mailing, main, or practice)

● Update your Patient and Appointment Options (i.e., accepting new patients)

Important information on updating your provider recordProviders are strongly encouraged to use the Provider File Management to update provider records. If Independence receives provider record updates that can be submitted using the Provider File Management transaction, a member of our eBusiness team may reach out to that provider to assist them in using the transaction to make the necessary updates. This will allow our team to receive user feedback on the transaction and help improve the overall user experience for our network.

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QUAL

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ENT New credentialing process and contact information

Published June 8, 2018

In an effort to streamline credentialing inquiries and reporting, Independence will be updating its credentialing administrative process and contact information.

Submitting credentialing and recredentialing inquiriesProviders should submit all initial credentialing and recredentialing inquiries to the following new email address: CredInquiries@ibx.com. Effective July 1, 2018, this email address also replaces the credentialing inquiry hotline (215-988-6534), which will be discontinued. Providers have the right to be informed of their credentialing or recredentialing application status upon request.

Making corrections on a credentialing applicationProviders have the right to correct any material omission or erroneous information within 30 calendar days of the request for clarification. Effective July 1, 2018, providers should submit supporting information or corrections concerning their initial credentialing or recredentialing application in writing to the Credentialing Operations Department:

● Email: CredOps@ibx.com (this replaces the current inbox: CredOpsmircr@ibx.com)

● Fax: 215-238-2549

More informationPlease note that the Quality Management section of the Provider Manual for Participating Professional Providers will soon be updated to reflect the changes outlined above.

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ENT Standards for medical record documentation:

Medical record reviewPublished June 26, 2018

A medical record documents a member’s medical treatment, past and current health status, and treatment plans for future health care. It’s an integral component in the delivery of quality health care. Independence has established standards for medical record reviews to facilitate communication, aid in coordination and continuity of care, and promote efficient and effective treatment.

Independence’s standards for medical record documentation are in addition to the medical record standards applicable to the provider under their state legislative agency and the requirements of the Health Insurance Portability and Accountability Act (HIPAA). Independence regularly assesses compliance with these standards and monitors the processes and procedures used by physician offices to facilitate the delivery of continuous and coordinated medical care. Performance goals have been established to assess the quality of medical record keeping. Below is a summary of the standards.

DocumentationEach medical record must include the following:

● a complete problem list; ● a prominent documentation of medication allergies and adverse reactions (if the member has no known

allergies or history of adverse reactions, this should be appropriately documented in the record); ● food and other allergies, such as shellfish or latex, which may affect medical management; ● past medical and surgical history, including prenatal, birth, and childhood illnesses for members ages 18 and

younger; ● current medications; ● documentation of clinical findings and evaluation for each visit; ● diagnoses consistent with findings; ● treatment or action plans consistent with the diagnoses; ● preventive services and risk screening.

ConfidentialityConfidentiality of medical records must be maintained as follows:

● Records are stored securely. ● Only authorized personnel have access to records. ● Staff receive periodic training in member information confidentiality.

OrganizationMedical records should be organized and kept as follows:

● Medical records are organized and stored in a manner that allows for easy retrieval. ● Medical records are stored in a secure manner that allows access by authorized personnel only.

The complete set of standards for maintaining appropriate medical records is accessible on our website. It can also be found in the Provider Manual for Participating Professional Providers, which is available in the Current Publications section of Independence NaviNet® Plan Central.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.

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IMPO

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Partners in Health UpdateSM is a publication of Independence Blue Cross and its affiliates (Independence) created to provide valuable information to the Independence-participating provider community that provides Covered Services to Independence members. This publication may include notice of changes or clarifications to administrative policies and procedures that are related to the Covered Services you provide in accordance with your participating professional provider, hospital, or ancillary provider/ancillary facility contract with Independence. Refer to the Provider News Center to stay up to date on news and information from Independence.

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2016 www.dreamstime.com. All rights reserved.This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer groups. Providers should call Provider Services for the member’s applicable benefits information. Members should be instructed to call the Customer Service telephone number on their ID card.The third-party websites mentioned in this publication are maintained by organizations over which Independence exercises no control, and accordingly, Independence disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services provided by or advertised in these third-party sites. URLs are presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefits plans. Members should refer to their benefits contract for complete details of the terms, limitations, and exclusions of their coverage.

NaviNet ResourcesNaviNet is our secure, online provider portal that gives you and office staff access to critical administrative and clinical data. To help you navigate the portal and various transactions, we have created a central location for a variety of NaviNet resources, including user guides, webinars, and a communications archive.

NaviNet Resources

Utilization ManagementCertain utilization review activities are delegated to different entities. Here you will find detailed information on our utilization management programs and common resources used among them.

Utilization Management

Opioid AwarenessWe have created a repository of tools and resources to assist you in managing your patients who are prescribed opioid medications.

Opioid Awareness Resources

Quick Links ● Bulletins ● Forms ● Medical Policy ● NaviNet Login ● Provider Home ● Services that require precertification

− Commercial − Medicare Advantage

Archives ● Partners in Health Update past edition PDFs ● Cumulative Index ● ICD-10 Transition

Email sign up ● Sign up for email from Provider Communications ● Sign up for email from our Network Medical Directors

Contact numbersPlease visit the Contact Information section of the Providers section of our website for a complete list of important telephone numbers.

Websites

Provider CommunicationsIndependence Blue Cross

1901 Market Street 28th Floor

Philadelphia, PA 19103

provider_communications@ibx.com

June 2018 | Partners in Health UpdateSM 30 www.ibx.com/pnc